A retrospective cohort study describing characteristics of those repeatedly detained under Section 136 of the Mental Health Act over a 5-year period and the association with past abuse

Abstract

Individuals repeatedly detained under Section 136 (S136) of the Mental Health Act account for a significant proportion of all detentions. This study provides a detailed analysis of those repeatedly detained (‘repeat attenders’) to a London Mental Health Trust, identifying key demographic profiles when compared to non-repeat attenders, describing core clinical characteristics and determining to what degree a past history of abuse might be associated with these.

All detentions to the S136 suite at South West London and St George's Mental Health NHS Trust over a 5-year period (2015–2020) were examined. Data were collected retrospectively from electronic records. A total of 1767 patients had been detained, with 81 patients identified as being a ‘repeat attenders’ (having had > = 3 detentions to the S136 suite during the study period). Repeat attenders accounted for 400 detentions, 17.7% of all detentions.

Repeat attenders included a higher proportion of females (49.4%, p = 0.0001), compared to non-repeat attenders, and a higher proportion of them were of white ethnicity (85.2%, p = 0.001). 52 (64%) patients reported being a victim of past abuse or trauma. Of repeat attenders who reported past abuse or trauma, a high proportion had diagnoses of personality disorders, with deliberate self-harm as the most common reason for detention. They were more commonly discharged home with community support, rather than considered for hospital admission. In light of these findings, this paper discusses support potential strategies for those most vulnerable to repeated S136 detention, thereby minimising the ever-growing number of S136 detentions in the UK.

Keywords

Forensic psychiatry medical law legal system law section 136 repeat detentions

Introduction

The UK is one of the only countries in Europe in which the police have legal powers to detain individuals believed to be suffering from a mental disorder.¹ In England and Wales, this is authorised by Section 136 (S136) of the Mental Health Act 1983 (MHA), enabling the police to remove an individual believed to be ‘suffering from a mental disorder and to be in immediate need of care or control’ from a public place to a designated place of safety, often a so-called S136 suite. A person can be detained for up 24 h, in order to allow further assessment to be arranged and a decision made about whether the person is suffering from a mental disorder that requires further assessment and/or treatment in hospital.^1,2

In three decades (1984–2014), there was approximately an eight-fold increase in detentions under S136 in English hospitals.³ Since 2017, S136 detentions in England and Wales have recorded a 12% increase.⁴ Individuals repeatedly detained under S136 account for a significant proportion of all S136 detentions; recent studies have found that those repeatedly detained account for between a fifth to a third of all S136 detentions.^5,6 This group takes up a significant proportion of NHS workload, resources and time, and therefore presents as a key focus for future research, when trying to reduce the number of detentions under S136 across the country.¹

It is recognised that personality disorders are prevalent amongst those detained under S136,^4,7,8 with many having experienced abuse during childhood.⁴ In a previous cohort, it was found that patients with personality disorders accounted for 87.5% of repeat detentions.⁸ It is common for those with personality disorders to report history of past abuse or trauma.⁹ Several studies have identified a strong relationship between childhood abuse or trauma and later suicide attempts.^10–12 A recent study found that individuals with repeated S136 detentions described complex histories of unresolved trauma, affecting their trust in mental health professionals, engagement with services and consequently leading them to rely more on police interventions in times of crisis.¹³ The actual prevalence of past abuse in repeat attenders is unknown, as is how this might impact on the specific clinical characteristics of those repeatedly detained or the care they receive. A better understanding of these characteristics in repeat attenders to the S136 suite could help identify future strategies for reducing crisis presentations.

The aim of this study was to undertake a detailed analysis of those repeatedly attending S136 suite at South West London and St George's Mental Health NHS Trust (SWLSTG) over a 5-year period. Authors wished to examine whether those with repeat detentions to the S136 suite would have a different set of demographics, with a unique set of characteristics, to which abuse might affect the clinical picture. Objectives were as follows:

To compare the core demographics of those repeatedly detained under Section 136 of the MHA with those not repeatedly detained

To provide qualitative descriptors of the core clinical characteristics of the repeatedly detained group, and to determine if abuse/trauma history is associated with the characteristics involved in repeat detention

To identify key strategies for future care of repeat attenders in SWLSTG Trust, with the aim of avoiding future unnecessary detentions

To our knowledge, this is the first study to have specifically focused, in such a detailed way, on a large group of individuals repeatedly detained in a S136 suite, whilst also considering the impact of past abuse.

Methods

All detentions to the S136 suite at South West London and St George's Mental Health NHS Trust (SWLSTG) were examined over a 5-year period (1 October 2015–30 September 2020).

Data were collected retrospectively from patient notes accessed on RiO, an electronic patient record system. Demographics were initially recorded for the entire cohort of patients detained under S136, recording gender, age at first detention and ethnicity. Comparisons were made between those repeatedly detained and those not repeatedly detained.

A repeat attender was defined as an individual who had had > = 3 detentions to the S136 suite during the study period. The definition of a repeat or frequent attender used in previous studies and the distribution of attendances to the S136 suite of SWLSTG between patients were considered when determining our definition of a repeat attender.^14–16 Since a relatively small group of patients with three or more detentions accounted for a large proportion of all detentions under S136 at SWLSTG from 2015–20, they were identified as a distinct group and formed our criteria for repeat detention (> = 3 detentions). Subjects with repeat or frequent detentions will hereafter be referred to as a ‘repeat attender’. If subjects had had S136 detentions prior to 1 October 2015, data related to their earlier detentions were also considered when recording clinical characteristics.

For repeat attenders, the focus of this study, the following additional parameters were recorded:

Additional demographics (employment, housing status, educational level)

Clinical characteristics (number of detentions, reasons for detention, treatment before first detention, previous involvement with mental health services, whether they were ever intoxicated on detention, past drug or alcohol history, past forensic history, confirmed diagnoses, outcomes of assessment), parameters based on those outlined in previous studies⁵

Prevalence of reported past abuse/trauma and type of abuse.

The Health Research Authority (HRA) tool was used when considering this project. It was concluded that this study is classified as a service evaluation rather than research, on the basis that subjects were not randomised, no intervention took place outside standard practice and that findings are not generalisable or transferable. The results reflect the experience at one trust and it is acknowledged that results would not necessarily be replicated elsewhere. St George's University of London Research and Governance team were consulted and it was confirmed that the study would not require approval by the local research ethics committee for the reasons highlighted above. The project has been registered with St George's University of London Research and Governance team and approval was granted to conduct the service evaluation (SE0029). The study was conducted following ethical principles in accordance with the Declaration of Helsinki. No patients were contacted during the process. All data were anonymised and treated securely.

Initial data were collected using Microsoft Excel for Windows by author LA, with discussion with author IM in any areas of uncertainty. Completed data collection was then fully cross-checked by IM and any discrepancies were clarified through further team discussion. Basic analysis was undertaken with Microsoft Excel with further statistical tests conducted using SPSS (SPSS, Chicago, Illinois, USA).

Results

1767 patients were identified to have been detained under S136 and attended the SWLSTG S136 suite in the 5-year period studied. 81 were identified as repeat attenders, having had three or more detentions over the relevant period. Repeat attenders accounted for 400 detentions (17.7% of all detentions), a similar proportion to previous studies.⁵ The distribution of patients and number of detentions are outlined in Figure 1.

Figure 1.

Flow chart showing the distribution of all patients detained under S136 between 1 October 2015 and 30 September 2020 at SWLSTG.

Comparison of repeat attender versus non-repeat attender demographics (n = 1767)

Demographics for the entire cohort are illustrated in Table 1 below. The repeat attender group had a higher proportion of females, making the M:F ratio almost equal, a significant difference from the non-repeat attender group where males were predominant (χ² = 1767; p = 0.0001***). Results also indicate a significant difference in ethnicity between the two groups, with repeat attenders including a much higher proportion of patients of white ethnicity (χ² = 21.9; p = 0.001**). No difference was noticed between the age distribution of the two groups.

Table 1.

Demographics of repeat attenders and non-repeat attenders (chi-squared and p-values set to 1 decimal place).

	Not repeat attenders (n = 1686)		Repeat attenders (n = 81)		Total (n = 1767)		Chi-squared value (χ²)	p- value	Signif.
	n	%	n	%	n	%		p- value	Signif.
Gender							1767.0	0.0001	***
Male	958	56.8	41	50.6	999	56.5
Female	728	43.2	40	49.4	768	43.5
Age (years) at first s136 detention							10.4	0.168	ns
10–19	163	9.7	16	19.8	179	10.1
20–29	506	30.0	21	25.9	527	29.8
30–39	426	25.3	21	25.9	447	25.3
40–49	303	18.0	14	17.3	317	17.9
50–59	202	12.0	7	8.6	209	11.8
60–69	64	3.8	2	2.5	66	3.7
70–79	18	1.1	0	0	18	1.01
80–89	4	0.2	0	0	4	0.2
Ethnicity							21.9	0.001	**
White	1032	61.2	69	85.2	1101	62.3
Black or Black British	234	13.9	3	3.7	236	13.4
Asian or Asian British	106	6.3	5	6.2	111	6.3
Other Ethnic Minorites	122	7.2	3	3.7	125	7.1
Mixed	86	5.1	1	1.2	87	4.9
Not stated	106	6.2	0	0	106	6.0

ns = non-significant.

Repeat-attender qualitative descriptors (n = 81)

A total of 81 people attended the S136 suite at SWLSTG three or more times during the five-year period investigated. As described above, the number of male (n = 41; 50.6%) and female (n = 40; 49.4%) patients was almost equal, notwithstanding the fact that females account for 43.5% of all attenders. Mean age at first detention under S136 was 32.4 years (SD 12.7). Repeat attenders were predominantly of white ethnicity, as discussed above (n = 69; 85.2%). Prior to first detention, the majority of patients were not in employment (n = 56, 69.2%). A large number had not achieved any formal qualifications (n = 34; 42%). The number of detentions under S136 of each patient ranged from 3 to 45, with mean of 6.16 (SD 5.9). Most patients had between 3 and 5 detentions (n = 51; 63.0%).

The most common single reason for detention under S136 was actual self-harm (n = 28, 34.6%). Prior to their first detention, most were already known to mental health services (n = 70; 86.4%) and most had previously been admitted to a psychiatric ward (n = 59; 72.8%). The majority of patients had a primary diagnosis of personality disorder (n = 41; 50.6%), followed by psychotic disorder (n = 22, 27.2%) and substance misuse (n = 12, 14.8%). 48 (55.6%) patients were intoxicated on arrival at the S136 suite and 37 (45.7%) had a reported alcohol history. 48 (55.6%) reported use of illicit drugs. The majority of patients had a reported forensic history (n = 59; 72.8%). Particularly notable findings described are illustrated in Table 2, with all parameters reported in supplementary materials.

Table 2.

Summary of clinical characteristics in repeat attenders, both those who reported past abuse and those who did not (chi-squared and p-values set to 1 decimal place, with expanded version in supplementary material).

	Those who report past abuse (n = 52)		Those who do not report past abuse (n = 29)		Total repeat attenderS (n = 81)		Chi-squared value (χ²)	p value	Signif.
	n	%	n	%	n	%		p value	Signif.
Gender							4.0	0.05	*
Male	22	42.3	19	65.5	41	50.6
Female	30	57.7	10	34.5	40	49.4
Age (years) at first S136 assessment							8.7	0.1	ns
10–19	13	25.0	3	10.3	16	19.8
20–29	17	32.7	4	13.8	21	25.9
30–39	10	19.2	11	37.9	21	25.9
40–49	7	13.5	7	24.1	14	17.3
50–59	4	7.7	3	10.3	7	8.6
60–69	1	1.9	1	3.5	2	2.5
Ethnicity							3.3	0.5	ns
White	46	88.5	23	79.3	69	85.2
Black or Black British	1	1.9	2	6.9	3	3.7
Asian or Asian British	2	3.9	3	10.3	5	6.2
Other ethnic groups	2	3.9	1	3.5	3	3.7
Mixed	1	1.9	0	0.0	1	1.2
Not stated	0	0.0	0	0.0	0	0.0
Number of S136 assessments							3.1	0.2	ns
3 to 5	30	57.7	21	72.4	51	63.0
6 to 10	14	26.9	7	24.1	21	25.9
>10	8	15.4	1	3.5	9	11.1
Primary reason for S136 detention							17.4	0.002	**
Bizarre behaviour	1	1.9	6	20.7	7	8.6
Threats of self-harm	6	11.5	5	17.2	11	13.5
Actual self-harm	25	48.1	3	10.3	28	34.6
Violence towards others	0	0.00	2	6.9	0	2.5
Violence to property	0	0.00	0	0.0	0	0.0
Combination	19	36.5	13	44.8	32	39.5
Hospital admission prior to first s136 detention							6.5	0.01	*
Yes	33	63.5	26	89.7	59	72.8
No	19	36.5	3	10.3	22	27.2
Primary confirmed diagnosis for S136 assessments							17.8	0.003	**
Substance misuse disorders	6	11.5	6	20.7	12	14.8
Psychotic disorders	8	15.4	14	48.3	22	27.2
Non-psychotic affective disorders	0	0.0	1	3.5	1	1.2
Anxiety disorders	3	5.8	0	0.0	3	3.7
Personality disorders	33	63.5	8	27.6	41	50.6
Developmental disorders	2	3.9	0	0.0	2	2.5
Most predominant outcome per patient							15.6	0.005	**
Formal admission	10	19.2	14	48.3	24	29.6
Informal admission	5	9.6	6	20.7	11	13.6
HTT	5	9.6	0	0.0	5	6.2
CMHT	8	15.4	4	13.8	12	14.8
GP only	19	36.5	2	6.9	21	25.9
Equal combination of 2 options	5	9.6	3	10.3	8	9.9

ns = non-significant.

The impact of abuse in repeat attenders (comparison of those who report abuse vs. those who do not report abuse)

52 (64%) patients reported being a victim of past abuse or trauma, as illustrated in Table 2. Notably, the prevalence of reported abuse was distinctly higher than the reported national statistic of 31% of individuals in the age group of 16–59 years who reported having experienced a form of abuse in childhood.¹⁷ Amongst general psychiatric patients, the prevalence of childhood and lifetime partner-based violence has been calculated as 47.5%¹⁸ and 30–33%¹⁹ respectively. The most common types of reported abuse in our cohort were sexual abuse (n = 23; 29%) and more than one abuse type, which included sexual abuse (n = 23; 28%) Figure 2.

Figure 2.

Past reported abuse history for repeat attenders (n = 81).

Comparison of clinical characteristics in those who reported abuse compared to those who did not report abuse is shown in Table 2. Past abuse in repeat attenders was found to be significantly associated with gender (χ² = 4.0; p = 0.05*), primary reason for detention (χ² = 17.4; p = 0.002**), hospital admission prior to first S136 presentation (χ² = 6.5; p = 0.01*), primary confirmed diagnosis (χ² = 17.8; p = 0.003**) and most predominant outcome per patient (χ² = 15.6; p = 0.005**). There was no significant association between past abuse and drug history (χ² = 1.5; p = 0.9), alcohol history (χ² = 0.01; p = 0.9) or forensic history (χ² = 13.7; p = 0.3).

Discussion

1767 patients were detained under Section 136 of the MHA and admitted to the SWLSTG S136 suite from 1 October 2015 to 30 September 2020. 81 had been detained three or more times over this period and accounted for 400 detentions (17.7% of all detentions), consistent with previous studies.⁵ Repeat attenders had an almost equal M:F ratio with the majority being of white ethnicity, a significant difference when compared to those not repeatedly detained. The South-West London general population includes 40.2% from ethnic minorities, however this study found that ethnic minorities were under-represented in South-West London S136 repeat-attenders.²⁰ The reasons for this are not clear, but might be associated with particular factors affecting police decision-making or other socio-cultural factors affecting presentations. Interestingly, previous studies have found that ethnic minorities, particularly those of Black or Black British ethnicity, have been historically more likely to be detained under S136, although these studies were not focusing specifically on repeat attenders.^21,22

Personality disorder was the most common primary confirmed diagnosis amongst repeat-attenders (n = 41, 50.6%). Actual self-harm was the most common reason for detention (n = 28, 34.6%). 38 (46.9%) repeat-attenders went home following S136 (under HTT, CMHT or GP). Of the 81 repeat attenders, 52 (64.2%) reported previous abuse, of which sexual was the most prevalent form, distinctly higher than reported levels from the general population and from psychiatric patients.^17–19 Those who reported abuse had significant differences in reasons for detention, primary diagnoses and eventual outcomes, with those who suffered abuse being more likely to return home. Some of these findings may not be altogether surprising, although they highlight the importance of consideration of past abuse, trauma and distress when undertaking S136 assessments on repeat attenders. Considering the level of distress to the abused individual (both past and present) and the fact that S136 presentations did not routinely lead to eventual admission, S136 detention might not have been the most desirable or effective option and may in fact have been countertherapeutic for these patients.

Results support the findings of past studies which identify a relationship between childhood abuse and trauma, suicide risk and S136 detentions.^10–13,23 Substance misuse is also worthy of consideration, as abuse during childhood has repeatedly been shown to increase the risk of later substance misuse.^24–26 Although substance misuse diagnoses showed a higher prevalence in non-abused individuals, as did psychotic disorders, no specific association was found between those abused and those not. Alcohol and drug history in repeat attenders were not found to be significantly associated with abuse history. Further study would certainly be warranted to investigate this further.

The main limitation of this study was that the clinical characteristics in repeat attenders to the S136 suite and the relationship between abuse/trauma history could not be compared to that of non-repeat attenders to the same suite. This is because this study focused on providing detailed qualitative descriptors for only this particular group of repeat attenders, due to the significant impact on NHS resources, time and workload. The data were collected over a 5-year period to get a sufficiently large sample size of repeat attenders and collecting data from non-frequent attenders would have been beyond the scope of this study. Results need to be interpreted with the proviso that there is no control group for all attenders when describing clinical characteristics, for the above reasons. Reporting bias was a possibility, either due to the patients not accurately reporting information or staff potentially introducing assumption bias when recording patient information. A significant amount of information was undocumented for several patients, particularly regarding employment status, housing status and education level, and therefore could not be included in the analysis. Finally, this service evaluation refers to the S136 repeat attenders of one London Trust Results are not immediately generalisable or transferrable to other health-care settings. We plan to develop this work, building on this data set by either collecting and analysing data from all detentions, so that comparisons can be made between repeat and non-repeat attenders, or by undertaking a case-control study to compare all characteristics of the 81 repeat attenders to a matched control group of non-repeat attenders. Combining and comparing data with other UK Mental Health Trusts could be an important next step to validate these findings.

The work indicates important considerations for the care of those repeatedly detained under S136. Adequate crisis and advance care plans for all patients presenting repeatedly to the S136 suite are crucial and sharing this information with police colleagues, providing consent is given, may allow police to make more informed decisions regarding who they detain in the future.¹ Further training for police on how to approach those with a trauma or abuse history and presenting in crisis is recognised as worthwhile, although it should not be a substitute for effective shared-working partnerships with mental health services.²⁷ In recent years, shared working has been developed through street triage, an intervention which combines mental health expertise with police encounters, aiming to reduce the likelihood of detention by police with the resulting patient distress. Most commonly, this has involved a co-response model, by which mental health professionals assist police in person during incidents.²⁸ Initial studies have shown a reduction in S136 detentions as a result of the co-response models, although the characteristics of service users repeatedly using street triage is unknown and therefore it is not yet clear who benefits from this service.²⁸ Service users have reported street triage to be more therapeutic, less traumatic and less stigmatising than the alternative and there have been suggestions that this particularly benefits repeat attenders, although previous literature acknowledges the need for further research.^28–30

For those already detained, determining how to address and manage abuse and trauma history in repeat attenders may help prevent future presentations. Immediate psychological support in the S136 suite could be considered, although this should not act as a substitute for stable consistent relational approach with a community team in the longer-term.¹³ Previous studies suggest that brief psychological therapy offered in an acute admission may be associated with reduced repeat admission and emotional distress.³¹ Psychological input in acute inpatient settings is perceived to be meaningful by service users so may allow those detained to feel more validated.³² Potential barriers may be cost limitations, feasibility and objective clinical effectiveness of such an intervention, given that the S136 setting would in all likelihood only permit 1 therapy session. An alternative may be to consider how psychologists might support S136 teams with formulations and care plans, shown to be of benefit in liaison psychiatry.³³

Since the COVID-19 pandemic, cases of both domestic abuse³⁴ and mental health crises³⁵ have risen in the United Kingdom and seeking help has become increasingly challenging. It has never been more crucial to recognise and support repeat attenders to the S136 suite, for whom these issues appear particularly pertinent Table 3.

Table 3.

Learning points from this cohort.

Repeat attenders to the S136 suite at SWLSTG have a higher proportion of females of white ethnicity, compared with non-repeat attenders

64% of repeat attenders report past abuse

Of the repeat attenders who reported abuse compared to those who did not, a higher proportion had a primary diagnosis of personality disorder, presented with actual self-harm and were more commonly discharged with community supports rather than admitted to inpatient ward

Authors hope that this paper will encourage other Mental Health Trusts to consider and examine their own practices with regards to repeat S136 detentions and trauma management

Supplemental Material

sj-docx-1-msl-10.1177_00258024211045456 - Supplemental material for A retrospective cohort study describing characteristics of those repeatedly detained under Section 136 of the Mental Health Act over a 5-year period and the association with past abuse

Supplemental material, sj-docx-1-msl-10.1177_00258024211045456 for A retrospective cohort study describing characteristics of those repeatedly detained under Section 136 of the Mental Health Act over a 5-year period and the association with past abuse by Laureen Adewusi, Isabel Mark, Paige Wells and Aileen O’Brien in Medicine, Science and the Law

Footnotes

Author contribution statement:

All authors meet ICMJE criteria for authorship. Laureen Adewusi undertook the majority of the study design, data collection/analysis and wrote the initial draft. Isabel Mark collected additional data, supported with data interpretation and revised the draft into its current format, following comments from other authors. Paige Wells contributed with data analysis and interpretation. Aileen O’Brien developed the initial concept for the project and article and provided advice throughout. All authors were involved in critical revisions and approved the final version. All authors are accountable for the work.

Conflicts of interest:

The Authors declare that there is no conflict of interest

Ethics statement:

Declarations

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Isabel Mark

Supplemental material

Supplemental material for this article is available online.

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